Hypotension in a Patient With Adrenal Insufficiency

Vital Signs

• Temperature: 102.0 °F, oral

• Blood Pressure: 85/60 mmHg

• Heart Rate: 110 beats per min, sinus tachycardia with peaked T waves on telemetry ( Fig. 56.1 )

  

• Respiratory Rate: 20 breaths per min

• Pulse Oximetry: 92% on 4 L O ₂ via nasal cannula

Focused Physical Examination

A quick exam revealed a middle-aged male in no apparent distress. He was awake but appeared lethargic, with slow but appropriate responses to questions. During the exam, it was noted that he was becoming more somnolent, and beads of sweat were starting to form over his forehead. He stated that he felt sick to his stomach and started to dry heave. A cardiac exam showed tachycardia with regular heart sounds. There were rhonchi noted over the left posterior lung fields on the lung exam. The neurological exam was non-focal.

Interventions

A cardiac monitor and pads were attached to the patient. Two large-bore IVs were established, and a 1 L bolus of Ringer’s lactate was started. Point-of-care-test (POCT) blood glucose level was checked, which was noted to be 60 mg/dL. He was administered 25 g of dextrose 50% IV. A stat EKG was negative for any acute ischemic changes; however, it showed peaked T waves in most leads. Stat blood tests were drawn. Complete blood count (CBC) and troponin tests were unremarkable. A comprehensive metabolic panel was concerning for a mild acute kidney injury and potassium level of 5.5 mEq/dL. Lactate was elevated at 4 mmol/L. His blood pressure failed to improve midway through the 1 L fluid bolus, and his clinical condition, especially his mental status, started deteriorating. Due to worsening hemodynamics, vasopressor support with norepinephrine was initiated. 100 mg IV hydrocortisone was administered for the suspicion of adrenal crisis in the setting of sepsis. Blood cultures were obtained, broad-spectrum antibiotics were ordered, and the patient was transferred to the intensive care unit (ICU) for further care.